The Single Psychotherapist

Amy Steinberg, a single mother and licensed clinical social worker in rural Harrison County, Mississippi, works four days per week at a community mental health center. On her day off, she provides services to a cooperative child care program that requires each participant to supervise the young children of program members one day per week. On the day that Amy is responsible for childcare, she receives a call from her supervisor, Sam Dellums, requesting that she make arrangements to come to work. In the aftermath of Hurricane Katrina in 2005, the federal government through the Substance Abuse and Mental Health Services Administration (SAMHSA) has made millions of dollars available for the provision of crisis counseling to hurricane victims. Now, several years after the disaster, local mental health agencies are continuing to apply these funds to the provision of ongoing follow-up care for the treatment of first responders—those police officers, fire fighters and other emergency workers who initially provided direct rescue efforts to victims. These first responders have in many instances suffered dual trauma as a result of the hurricane, meaning that they have been impacted not only through occupational exposure to victims suffering through the disaster, but also through personal exposure to the event itself. Now, some years after the hurricane, a good number of first responders are apparently continuing to experience the lingering effects of this trauma. The ongoing, apparent surge in mental health symptoms among first providers has thrown Harrison County off guard; county leaders are blaming a significant amount of employment absenteeism by police officers and fire fighters on enduring “hurricane-related illness.” In addition to missing work, an ever-growing number of first responders seem to be displaying problematic behavioral symptoms in their employment, including agitation, anger, and other work-related personal problems that are being attributed by public safety officials to long-term “hurricane duty.”Sam concurs in this opinion, and he is ready to address the ostensible problem by promising county leaders that he would increase the number of therapy hours available for crisis counseling and related services at the mental health center. Luckily, he has the federal dollars to commit to this enhanced intervention. Based on this fact, an increasing number of public safety workers are being referred to the mental health center for follow-up crisis counseling.

Sam explains to Amy that the center has much money remaining from the direct federal grant that must be applied to counseling services. Amy is told that her services are urgently required to provide this counseling, but, Sam tell her, Amy’s decision to come to work on her day off would be on a strictly voluntary basis. As Sam puts it to her, “I know you’ve got other things on your plate.” On the particular day in question, Amy could arrange for substitute child care, but it would require her to contact each of the other parents and the cost of getting the substitute care would be borne by Amy.

This dilemma is a variation on a classic example often presented in mental health ethics texts. It is sometimes described as a “conflict of interest” pitting the provider’s personal interests against potentially superseding professional obligations. If characterized in this way, the dilemma is misleading and unfairly depicts the professional’s choices. Analyzing the dilemma becomes especially confusing if the decision maker seeks guidance first from an ethical code, mainly because of the aspirational nature of many of the standards and values expressed. In contrast, if the duty to identify the primary client is applied to the dilemma, Amy will recognize at first that at the time of the initiation of the dilemma she has established no professional relationship with a client and owes no specific legal duty to an identified person. If she has any legal obligation at all, it is in her role as a parent and caretaker for the cooperative childcare program, and it is owed solely to her own child and the additional children in her temporary custody.

Before one jumps to the conclusion that this is an unfeeling and hypertechnical response to a major public tragedy, consider the benefits of a legal analysis to all those involved. First, if Amy falsely assumes in this scenario that an official duty obliges her to provide a service, she takes on a risk that she simply may be unprepared to accept, and unreasonably elevates a presumed responsibility above her personal commitments. If Amy makes this mistake, or instead seeks guidance initially from the NASW Code of Ethics, which as noted previously obscures the very meaning of the term “client,” she may easily be overwhelmed by a multitude of considerations. In reality, no legal conflict of interest exists in this dilemma. Amy’s obligations here are strictly personal, and as a compassionate professional—but prudent mother and caretaker—she can reasonably decline to offer services immediately.

How insensitive is this decision? Honoring one’s personal commitments before making a decision to undertake a professional service may be the surest way to provide competent services once one voluntarily enters into a professional relationship. Put differently, in Amy’s situation, a rushed decision to provide services prematurely may do more damage to her own family than it does good for the prospective clients. The risk to these clients includes an incompetent clinical intervention by a therapist preoccupied with personal responsibilities. The lingering mental health issues caused by the hurricane may or may not require the assistance of therapists to the degree proposed by county leaders and the mental health center; indeed, Sam seems as much concerned with spending the mental health center’s grant money as with the continuing outbreak of symptoms among first providers. Though the prevalence of mental health problems among first providers might be a serious enough problem to throw Harrison County into a continuing crisis mode, any surge to offer them treatment runs the risk of imposing services on people who have not voluntarily sought them. In fact, an under-planned, over-response is sometimes observed during the human tragedy caused by natural disasters. Indeed, research has suggested that the very act of intervening in an excessive or inappropriate manner with first responders may contribute to the behavioral problems themselves. For example, there are numerous reports of first responders simply walking out of debriefing sessions with their superiors because of the fatigue and frustration caused by seemingly endless discussions of the tragic events. All things considered, one can reasonably question whether the requisite degree of voluntariness on the part of prospective clients is being sought in the mental health center’s zeal to provide services.

Clearly, Amy owes the children in her charge her primary attention. At a time when her principal responsibilities to family and youngsters in need of child care have been fully satisfied, Amy may agree to offer crisis intervention services as requested, according to the terms of her employment, or, perhaps, during limited overtime hours. In this way, both Amy and her prospective clients will be more likely to have entered into a professional relationship thoughtfully and voluntarily.

Amy’s dilemma highlights a general misapprehension about mental health services that may represent the most serious cause of professional burnout among caregivers. Specifically, it underscores the point that a professional’s obligations are neither unceasing nor boundaryless in their extent. Ethical codes sometimes add to the professional’s role confusion by reciting broad goals that are well intended but at times unattainable, most notably by failing to define adequately the meaning of client. Until a professional relationship is formed and a legal bond between a provider and primary client is established, most ethical aspirations simply cannot be enforced.